Mood Chart

Adapted from Sachs, G (1996): J. Clin. Psychopharm. 16:2(suppl 1) p47S

Exercise /Medication (enter amounts, note dose changes)
Exercise type How long med 1 med 2 med 3 med 4

Date

Energy/Mood
(can use two check marks: worst and best for each day) Low Agitation/ nl energy/mood anxiety/ up
impaired not impaired not impaired impaired normal mood cannot work cannot work

Sleep check one, or hours

increased sleep

Irritability 0-3 scale

Events/Notes/Observations Questions to ask, connections you suspect;

(circle for menses)

Walk Swim Run Bike Etc.

mg mg mg mg

or significant events that might affect mood interactions, successes, disappointments, anniversaries, illness, losses, etc.

normal sleep

insomnia

+++

++

++

+++

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

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Adapted by Peter M. Brigham, MD 1997-8

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